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Brandon House Enrollment Form

Select the program the student is seeking enrollment.
Participant Information
Please enter the name of student who would be enrolled in Brandon House Programs.
First Name
Middle Initial/Name
Last Name
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Country
Address Line 1
Address Line 2
City
State
Postal Code
Parent/Guardian Information
Must be completed by Parent/Guardian if the participant is under the age of 18. Otherwise, information can be completed by the participant. 
Prefix
First Name
Middle Initial/Name
Last Name
Suffix
Prefix
First Name
Middle Initial/Name
Last Name
Suffix
Country
Address Line 1
Address Line 2
City
State
Postal Code
Country
Address Line 1
City
State
Postal Code
Phone Number
ext Extension
Emergency Contact Information
Prefix
First Name
Last Name
Prefix
First Name
Last Name
School Information
indicate the highest level education attained OR the grade in which participant is enrolled.
Participant Health & Safety Information
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Does your student have health insurance?
Does your student take any medication?
Any known allergies?
If yes, indicate what kind of allergies your student has.
Indicate what kind of food or animal allergies your student may have.
Does your student carry an Epi-Pen?
Has participant ever had a Psychological Assessment?
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Does your student have a physical disability?
Does your student have any chronic health problems?
Does your student attend counseling sessions?
Is your student enrolled in residential treatment?
Has your student ever been diagnosed with any of the following?
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Does your student have any dietary restrictions?
PARENTAL MEDICAL & HOLD HARMLESS CONSENT

Knowing there is a certain amount of risk involved in even the simplest of program activities, I give my permission for my child to participate in Brandon House Cultural & Performing Arts Center, [herein referred to as Brandon House] activities and programs.  I accept responsibility in the unlikely event that an accident might take place and I understand that Brandon House is not liable for personal injuries and/or property damage to my child.

I understand that in the unlikely case of an accident for my child I am solely responsible for the cost of health care for my child, even as a result of my child’s participation in Brandon House programs or activities.  

I hereby consent to my child being given emergency treatment by a physician or hospital in case of an accident due to his/her taking part in Brandon House programs.  I understand that Brandon House does not cover my child with any primary medical insurance coverage and that the parent/guardian is financially responsible for any treatment provided.

I hereby agree to hold harmless Brandon House, members of its board, staff, and authorized volunteers for accidental injury to my child or damage to my child’s property.  I give permission for my child to participate in all program activities, and do forever release Brandon House and its members of the board, staff, volunteers and agents from any and all actions, all known and unknown personal injuries or property damage to my child arising out of any and all Brandon House activities.  I also forever release Brandon House of any and all claims or right of action for damages which my child has or hereafter may acquire as a result of participation at Brandon House.

 

Do you consent?
FIELD TRIP PERMISSION

Occasionally, your child may be invited on a field trip as part of the after school or summer program. In the event of a field trip, you will receive detailed information about the proposed trip.  By signing electronically below, you give Brandon House permission to transport your child to and from any field trip opportunity.

Do you consent?
PARENTAL RELEASE

Please read and check mark the following statements before electronically signing below:

I/We the parent/guardian agree that we have read completely and agree to the information stated in this application for my child to participate in Brandon House programs and activities.  I/We agree that the information provided is accurate and we/I agree to all the information contained in this application.

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